J Gandhara Med Dent Sci

ORIGINAL ARTICLE

USE OF TRIPHASIC CT LI-RADS V 2018 IN PATIENTS UNDERGOING DYNAMIC CONTRAST-

ENHANCED CT LIVER FOR HEPATIC LESION CHARACTERIZATION

Humaira Anjum

, Samia Iftikhar

ABSTRACT

OBJECTIVES

This study aimed to characterize hepatic observations and evaluate the

frequency of LI-RADS v2018 categories in a high-risk Pakistani population

using triphasic CT.

METHODOLOGY

A retrospective cross-sectional observational study was conducted at the

Radiology Department of Khyber Teaching Hospital in Peshawar from

March 2021 to September 2022. Fifty-ve high-risk patients

(cirrhosis/chronic hepatitis B) underwent triphasic CT, and 80 Observations

were independently categorized by two radiologists using LI-RADS v2018

major features. Histopathological correlation was assessed where available.

RESULTS

Out of 55 patients (80 observations) in our study, the LI-RADS distribution

was: LR-5 in 61 (76.25%), LR-4 in 4 (5%), LR-M in 3 (3.75%), LR-TIV in 7

(8.75%), LR-1/2/3 in 5 (6.25%). Non-rem arterial phase hyperenhancement

was the most frequent feature (81.3%). All LR-5 lesions showed non-rim

APHE and washout. In the subset with histopathology (n=12), LR-5 showed

100% concordance with HCC (7/7), and LR-M showed 100% concordance

with cholangiocarcinoma (3/3).

CONCLUSION

Triphasic CT LI-RADS v2018 eectively categorized hepatic ndings in high-

risk Pakistani patients, with LR-5 being the most frequent category and

demonstrating strong histopathological correlation; however, the high LR -5

prevalence suggests potential selection bias inherent to the referral-based

setting. The system provides a standardized reporting framework suitable for

local clinical practice.

KEYWORDS: Hepatocellular Carcinoma, Liver Imaging Reporting and

Data System (LI-RADS), Dynamic Contrast-Enhanced CT, Triphasic CT,

Pakistan

How to cite this article

Anjum H, Iftikhar S. Use of Triphasic

CT LI-RADS V 2018 in Patients

Undergoing Dynamic Contrast-

Ehanced CT Liver for Hepatic Lesion

Characterization. J Gandhara Med

Dent Sci.2026;13(1):18-22.

Date of Submission: 16-10-2025

Date Revised: 15-12-2025

Date Acceptance: 16-12-2025

Assistant Professor, Department of

Radiology, Hayatabad Medical

Complex, Peshawar

Correspondence

Samia Iftikhar, Specialist Registrar,

Department of Radiology, Hayatabad

Medical Complex, Peshawar

+92-333-9459513

samiaifthikhar.123@gmail.com

INTRODUCTION

Hepatocellular carcinoma (HCC) is a prevalent form of

hepatic cancer and ranks fourth among deaths from

cancer globally. Cross-sectional imaging plays a vital

role in HCC diagnosis and management, obviating the

need for invasive biopsy procedures.

1,2

Ultrasound

surveillance is performed regularly in patients with

chronic liver disease for HCC screening. Although

HCC is more common in cirrhosis patients, a wide

range of lesions, ranging from benign regenerative

nodules to malignant lesions, can occur.

These non-

malignant entities can exhibit similar imaging

characteristics to HCC, resulting in diagnostic

ambiguity and potentially incorrect treatment

decisions.

Tri-phasic CT and MR Imaging is used in

this situation to distinguish HCC from other

malignancies and benign lesions in cirrhotic liver.

The

American College of Radiology (ACR) introduced the

Liver Imaging Reporting and Data System (LI-RADS)

to facilitate the diagnosis and management of HCC in

high-risk patients. The system comprises a diagnostic

algorithm, a lexicon, and recommendations for

standardized interpretation, reporting, data collection,

and imaging techniques. It categorizes liver

observations on CT and MRI in patients with cirrhosis,

chronic hepatitis B infection (even in the absence of

cirrhosis), or a prior history of HCC by analyzing

primary and ancillary imaging features to indicate the

likelihood of malignancy.

1,2,5,6

The 2018 update

introduced new criteria, classifying small liver lesions

(10-19 mm) that show arterial phase hyperenhancement

(APHE) and washout as LR-5.

7,8

LI-RADS classies

liver observations based on primary and ancillary

imaging characteristics to determine the relative

likelihood of HCC, non-HCC malignancy, and benign.

These categories include LR-1, which indicates that the

observation is denitely benign, LR-2, which suggests

a high probability of benignity, LR-3, which represents

an intermediate probability of HCC, LR-4, which

indicates a high probability of HCC, LR-5, which

https://doi.org/10.37762/jgmds.13-1.767

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J Gandhara Med Dent Sci

represents a denite diagnosis of HCC, LR-TIV, which

is a denite diagnosis of HCC with the tumor in vein

and does not require visualization of a parenchymal

mass, and LR-M, which suggests malignancy but not

specific for HCC and is indicative of non-HCC

malignancy with rim arterial phase hyperenhancement.

LR-3, LR-4, and LR-5 observations can be

distinguished based on major imaging characteristics.

These include non-rim arterial phase hyperenhancement

(APHE), size and diameter (< 10 mm, 10-19 mm, ≥ 20

mm), washout appearance (attenuation loss in the

venous and/or delayed phase), presence of enhancing

capsule during the portal venous or delayed phase, and

threshold growth rate (growth >50% in ≤6 months).

1,2

While MRI is often considered the preferred modality

for LI-RADS application given its superior soft-tissue

contrast, triphasic CT remains a widely available,

faster, and more accessible rst-line multiphasic

imaging tool in many clinical settings, including

resource-constrained environments. Moreover, there is

a notable gap in the literature regarding the systematic

application and performance of CT-based LI-RADS

v2018 in specic populations, particularly in regions

like Pakistan, where aetiology, stage at presentation,

and healthcare infrastructure may dier from those in

the populations in which the system was primarily

validated. In Pakistan, HCC is prevalent and ranks high

among cancers aecting the adult population, yet the

utilization and impact of a standardized reporting

system like LI-RADS in routine radiological practice

remain poorly documented. Therefore, this study aims

to evaluate the frequency distribution of LI-RADS

categories and the diagnostic performance of major CT

features in a high-risk Pakistani population undergoing

triphasic CT. We seek to determine the feasibility and

reliability of implementing this standardized framework

to improve diagnostic consistency, enhance

communication between radiologists and clinicians, and

ultimately support optimized patient management

pathways in our local context.

METHODOLOGY

A retrospective, observational study was conducted at

the Radiology Department of Khyber Teaching

Hospital, Peshawar, from March 2021 to September

2022. The study included 55 consecutive adult patients

(>18 years) meeting the LI-RADS v2018 diagnostic

population criteria: those with cirrhosis (any aetiology),

chronic hepatitis B virus (HBV) infection (with or

without cirrhosis), or a prior history of hepatocellular

carcinoma (HCC) who underwent a triphasic CT

abdomen for hepatic lesion evaluation.

Patients with

cirrhosis due to congenital hepatic brosis, vascular

disorders (e.g., hereditary haemorrhagic telangiectasia,

Budd-Chiari syndrome), or diuse inltrative

conditions that mimic HCC were excluded.

All

examinations were performed using a Canon Aquilion

Prime 160-slice multidetector CT scanner. The triple-

phasal contrast-enhanced study includes the arterial

phase (late arterial phase recommended), portal venous

phase, and delayed phase. Unenhanced images if the

patient has previous loco-regional treatment. CT images

were independently reviewed on a PACS workstation

by two radiologists with 5 years of experience in

abdominal imaging. Each identied liver observation

was evaluated for LI-RADS v2018 major features: size,

non-rim arterial phase hyperenhancement (APHE), non-

peripheral "washout" appearance, enhancing "capsule,"

and threshold growth. For this preliminary study, which

focused on the core algorithm, ancillary features were

not considered, and threshold growth was not assessed

due to the frequent lack of prior or follow-up imaging.

Each observation was assigned a nal LI-RADS

category (LR-1 to LR-5, LR-M, or LR-TIV) based

strictly on the combination of major features present,

following the LI-RADS v2018 diagnostic table. In

cases of discrepancy, a consensus reading was obtained

through joint review. Demographic data, clinical history

(etiology of liver disease, cirrhosis status), were

recorded from electronic medical records.

Histopathological conrmation, when available, served

as the reference standard and was obtained via

percutaneous biopsy or surgical resection. For patients

without histopathology, the assigned LI-RADS

category itself was used as the imaging-based risk

stratication endpoint, reecting the system‘s intended

clinical use. Categorical data are presented as

frequencies and percentages. The positive predictive

value (PPV) was calculated for LR-5 and LR-M

categories based on histopathological conrmation. A

p-value of <0.05 was considered statistically

significant. All analyses were performed using IBM

SPSS Statistics version 22.

RESULTS

A total of 55 patients (35 males, 20 females) with a

mean age of 49 ± 10 years (range: 32-78 years) were

included. All patients met LI-RADS v2018 diagnostic

criteria: 42 (76.4%) had cirrhosis (primarily due to

hepatitis C virus [HCV] and hepatitis B virus [HBV]),

10 (18.2%) had chronic HBV without cirrhosis, and 3

(5.5%) had a history of previously treated HCC. Eighty

(80) distinct hepatic observations were identied and

categorized using LI-RADS v2018 criteria. The

distribution of LI-RADS categories is summarized in

Table 1. Of the 55 patients, 3 (5.5%) had no detectable

observations. Two patients (3.6%) had concurrent LR-5

and LR-4 lesions. All 61 LR-5 lesions (100%) exhibited

Use of Triphasic CT Li-Rads V 2018 in Patients Undergoing

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Use of Triphasic CT Li-Rads V 2018 in Patients Undergoing

non-rim arterial phase hyperenhancement (APHE) and

non-peripheral washout. An enhancing capsule was

observed in 30 (49.2%) of LR-5 lesions. The frequency

of signicant features in LR-4 and LR-5 observations is

detailed in Table 2. Overall, non-rim APHE was the

most frequently observed central feature across all

observations (65/80, 81.3%). All three LR-M

observations (3.75%) exhibited rim APHE and were

later conrmed as cholangiocarcinoma on

histopathology. Histopathological conrmation was

available for 12 of 55 patients (21.8%) through biopsy

(n=9) or surgical resection (n=3). The correlation

between LI-RADS categorization and nal

histopathological diagnosis is presented in Table 3.

Table 1: Distribution of LI-RADS Categories

(n = 80 Observations)

LI-RADS

Category

Observations

with

Pathology(n)

Confirmed

diagnosis (n)

PPV

(95% CI)*

LR-5 07 HCC (7) 100%

(59.0% - 100%)

LR-4 02 HCC (1),

Dysplastic

Nodule (1)

50%

(1.3% - 98.7%)

LR-M 03 Cholangiocarc

inoma (3)

100%

(29.2% - 100%)

*PPV = Positive Predictive Value; CI = Condence Interval. Note:

For patients with multiple observations, the highest LI- RADS

category was used for correlation.

Figure 1: 40-year-old Male Patient with HBV Cirrhosis, LR-5. An

Arterial Phase CT Demonstrates a 16.8x13.4x13.5 mm

(APxTRxCC) Non-Rim APHE Lesion in Segment 5 (arrow),

Which Shows Non-Peripheral Washout in Both b Venous

and c Delayed Phases (Arrows). The Lesion Was Categorized as

LR-5 (HCC).

Figure 2: 40-year-old Male Patient with Cirrhosis, LR M. An

Arterial Phase CT Demonstrates 8.8x10.4x9.4 cm (APxTRxCC)

Rim APHE Lesion Segment 5 and 6, Which Shows Peripheral

Washout in both b Venous and c Delayed Phases (Arrows), No

Other Feature. LR-M (Biopsy-Proven Cholangiocarcinoma)

DISCUSSION

This study evaluated the application of LI-RADS v2018

in a Pakistani cohort undergoing triphasic CT for

hepatic lesion characterization. This study evaluated the

initial application of the CT LI-RADS v2018 algorithm

in a high-risk Pakistani population, demonstrating its

feasibility as a standardized diagnostic framework in a

setting where triphasic CT is the rst-line multiphasic

imaging modality. The majority of observations

(76.25%) were categorized as LR-5, indicating a

definite diagnosis of HCC, which aligns with the high-

risk prole of our study population. This proportion is

notably higher than that reported in a study by Tang ES

et al, which typically reports LR-5 rates of 31.4% in

surveillance cohorts.

This discrepancy likely does not

reect a failure of the algorithm. Instead, it underscores

a critical characteristic of our study population:

selection bias inherent to a tertiary care, referral-based

setting, a known challenge in resource-limited

environments where surveillance programs are

underutilized. Our cohort comprised patients already

suspected of having focal liver disease based on

symptoms, abnormal surveillance ultrasound, thereby

enriching the sample with advanced, imaging-

overlapping malignancies. Consequently, our results

validate LI-RADS for diagnosis and staging in

symptomatic patients, while its performance in a proper

screening context within our region requires further

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Use of Triphasic CT Li-Rads V 2018 in Patients Undergoing

study. In this study, APHE was the predominant feature

(present in 81.3% of all observations and 100% of LR-5

lesions), consistent with prior studies highlighting its

critical role in HCC diagnosis.

12,13,14

All LR-5 lesions

demonstrated both non-rim APHE and washout,

reinforcing the high specicity of this combination for

HCC.

10,13

The frequency of enhancing capsules (49.2%)

in our LR-5 observation was slightly higher than that

reported by Granata V et al. (37.2%).

This variance

may be attributed to the larger average size of LR-5

lesions in our cohort (85.2% were ≥20 mm), as capsule

visualization is positively correlated with lesion size

and may also be inuenced by delayed phase timing.

The algorithm also demonstrated high utility in

suggesting non-HCC malignancies. We found that rim

APHE was the most characteristic feature of LR-M, and

all three were subsequently conrmed as

cholangiocarcinoma on histopathology, yielding a PPV

of 100% in this small subset. Our results align with the

established LI-RADS literature, in which rim APHE is

recognized as one of the most specic LR-M features.

Chernyak V et al reported that rim APHE is

conceivably the most prevalent LR-M characteristic.

Furthermore, in our study, LR-TIV was seen in 7

patients who had LR-5 observations. This result was

consistent with observations in a study by Khanna et al

which revealed that all lesions classied as LR-TIV

were HCC.

The presence of LR-TIV in association

with LR-5 lesions further supports the system‘s ability

to identify aggressive tumor behaviour, consistent with

established literature.

Robust external validators

supported the LI-RADS categorization.

Histopathological correlation, available in a subset of

patients (21.8%), demonstrated strong diagnostic

performance of LI-RADS categorization. All LR-5

lesions (7/7) with available histopathology were

confirmed as HCC, yielding a 100% positive predictive

value (PPV) for this category. Our results are consistent

with those of a previous study, which reported 100%

(9/9) of LR5 observations conrmed as HCCs.

Similarly, all 3 LR-M observations were conrmed as

cholangiocarcinoma, validating the system's utility in

suggesting non-HCC malignancies. Of the two LR-4

lesions with histopathological correlation, one was an

HCC and a dysplastic nodule. Our nding that one of

two LR-4 lesions was HCC (50%) aligns with the core

premise of the LI-RADS category, reinforcing that LR-

4 observations signify a high probability of malignancy,

as supported by a prior study in which 65.6% were

HCC.

In contrast, our small sample showed a higher

rate of dysplastic nodules (50% vs. 6.3%) and no

instances of a non-correlating benign nding (compared

to 28.1% in the prior study, discrepancies are most

reasonably attributed to the profound limitation of our

minimal cohort size (n=2), which is highly susceptible

to sampling variation, coupled with the methodological

dierence of targeted histopathological correlation

rather than whole-liver explant analysis, the latter being

the gold standard for identifying imaging false

positive.

Despite the numerical variances, the key

clinical implication is consistent: LR-4 observations

require prompt diagnostic or therapeutic management.

In line with LI-RADS guidance, LR-3 observations

may benet from short-term follow-up or further

evaluation with MRI, while LR-4 and LR-5

observations should be managed within a

multidisciplinary team framework. In settings where

uncertainty persists-particularly for LR-3 and LR-4

lesions-biopsy may be considered on a case-by-case

basis.

LIMITATIONS

This study has several important limitations. First, its

retrospective design at a single center and modest

sample size limit the generalizability of our ndings.

Second, our LI-RADS application was limited to major

features; ancillary features were not evaluated, and

threshold growth could not be assessed due to the lack

of prior or follow-up imaging for many patients. This

deviation from the complete LI-RADS algorithm may

have inuenced the categorization of indeterminate

observations. Third, although it reects real-world

clinical practice, in which imaging often guides

management, the limited availability of

histopathological conrmation for all lesions limits

definitive validation, particularly for LR-3 and LR-4

categories. Fourth, we did not formally assess inter-

observer agreement among radiologists, a key metric

for the reproducibility of any standardized reporting

system. Finally, potential selection bias exists as our

cohort comprised referred, high-risk patients, which

may explain the high observed prevalence of LR-5

lesions and is an important consideration when

interpreting our results. Despite these limitations, our

findings suggest that triphasic CT LI-RADS v2018 is a

clinically valuable tool for standardizing liver

observation reporting in high-risk Pakistani patients,

facilitating clear communication among specialists for

timely management.

CONCLUSIONS

In this preliminary evaluation, CT LI-RADS v2018

provided a feasible and reliable framework for

standardizing liver lesion reporting in our high-risk

Pakistani population. The system eectively

categorized the majority of observations, with LR-5

being the most frequent outcome, demonstrating strong

histopathological correlation. The high positive

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Use of Triphasic CT Li-Rads V 2018 in Patients Undergoing

predictive value observed for LR-5 and LR-M

categories supports its diagnostic utility in our clinical

setting. However, the high prevalence of LR-5 lesions

warrants consideration of potential selection bias. Non-

rem arterial-phase hyperenhancement was the most

sensitive central feature for HCC. To further validate

and optimize LI-RADS performance in local and

regional contexts, future prospective, multi-centre

studies incorporating ancillary features, longitudinal

imaging, inter-observer reliability assessment, and

broader histopathological correlation are recommended.

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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AUTHORS CONTRIBUTION

The authors accept responsibility for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

Humaira Anjum – Concept & Design; Data Acquisition;

Drafting Manuscript; Supervision; Final Approval

Samia Iftikhar – Concept & Design; Data Acquisition;

Drafting Manuscript; Critical Revision; Final Approval

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